Operative Setup

Chapter 8. Operative Setup

Rhinoplasty is best performed in a supine or head-up position on an operating room bed or flexed operating chair. A circular cushion is placed at the occiput to support the head and a shoulder roll is placed transversely behind the shoulders to gently extend the neck. The arms are placed at the sides with padding beneath the elbows to avoid ulnar nerve injury due to prolonged compression.

Lighting is of key importance since certain structures may be hidden in shadow beneath overlying soft tissue. Overhead operating lights are often insufficient and a headlight is recommended. This allows the surgeon to direct a focused beam of light onto the working area. Suction/irrigation devices with a light incorporated into the tip may also be useful.

Anesthesia for rhinoplasty is largely determined by surgeon preference and the need for adjunctive procedures. Local anesthesia with or without intravenous sedation may be perfectly adequate for many patients and may be administered safely. This is typically indicated for modification of the soft tissues rather than osteotomies. Intravenous propofol may be used and titrated to a level of adequate sedation without losing spontaneous respiration. Many patients and surgeons alike prefer general anesthesia because it minimizes patient sensation during the procedure and allows the anesthesiologist to safely control the patient’s blood pressure as a means of minimizing blood loss. If bleeding is to be expected, a protected airway is advantageous in that it reduces the chance of laryngospasm. The sedated patient is breathing spontaneously, and the protective cough reflex is blunted. If blood or irrigation lands on the vocal cords, laryngospasm may be induced, creating an airway emergency. With a secure airway, this potential complication can be avoided. The need to harvest bone or cartilage from a remote site, such as calvarium or rib, also makes general anesthesia a preferable choice. If general anesthesia is chosen, the endotracheal tube (ETT) or laryngeal mask airway (LMA) is best taped so that it does not interfere with exposure of the tip or osteotomies. An ETT or LMA that is taped at the corner of the mouth may pull the oral commissure and thus the nasal tip resulting in a tip deviation that may confound the surgeon’s ability to assess tip symmetry.

In addition to setting up the operative instruments on a larger sterile table, a small prep table should be used. This should include a speculum, small scissors, Bacitracin, as well as an antimicrobial solution, pledgets soaked in a vasoconstrictive solution, a 10 cc syringe with 1% lido-caine with 1/100,000 epinephrine, and a 1½ inch 25-gauge needle. The speculum is used to confirm the preoperative findings from the intranasal examination.